Somatosensory Symptoms

Sensory complaints are frequent among the earliest symptoms of MS with a recent survey indicating that they were the first manifestation in 43% of patients, but this figure may have included visual as well as somatosensory phenomena (47).

The symptoms are often perplexing for the clinician, especially during the onset bout, because they are frequently unassociated with objective signs on the neurological examination. In addition, the anatomical distribution is often peculiar, not corresponding to recognized dermatomal, peripheral nerve, or homuncular patterns. Patients usually complain of numbness, but more often are referring to a subjective positive sensation than to diminished or absent sensation. Common complaints include tingling, burning, tightness, a feeling like ''procaine (Novocaine) wearing off,'' or a sensation that a garment, such as a glove or a girdle, is being worn. Often the abnormal sensation occurs in a band-like fashion around a limb or the abdomen. Sometimes only a patch of abnormal sensation is reported.

These complaints likely reflect lesions of the myelinated posterior columns (fasciculi gracilis and cuneatus), rather than the spinothalamic tracts (36). In contrast, objective sensory signs of diminished pain and temperature sensation indicate involvement of the latter pathways. Vibratory sense impairment is extremely common and almost always precedes detectable abnormality of joint position sense. The author has observed subtle reduction in the ability to perceive a vibrating tuning fork in many mildly affected patients early in the course of the disease.

Reduced perception of pinprick or temperature sensation is less frequently seen. It, too, has a variable pattern of distribution, but may show a spinal cord level. A picture resembling Brown-Sequard syndrome is occasionally seen (48).

A fairly specific sensory symptom of MS is Lhermitte's sign (a misnomer, since this is a subjective complaint) (49,50). Patients complain of sudden electric-like sensations radiating down the spine or extremities for a brief moment. This typically occurs when flexing the neck.

In a recent survey, 67% of patients with MS reported pain at some point in their disease course, a frequency comparable to that of controls (47). However, twice as many patients with MS reported active pain than did the control group. They also tended to have pain most often in the extremities and trunk, whereas the controls more often reported head, back, and neck pain. Several distinct pain syndromes may occur in MS patients. Some experience severe, lancinating neuralgic pains in the limbs or elsewhere; others complain of more persistent, intolerable dysesthesias, frequently with a burning quality (42,43). Patients with spasticity often report painful spasms or cramping sensations in the legs.

Although low-back pain is a very common ailment among the general population, it is perhaps even more among persons with MS. This may be related to abnormal postures and gaits associated with weakness and spasticity. Radicular pain may occur occasionally in the absence of compressive pathology and, in one report, was the presenting complaint in 3.9% of patients with newly diagnosed MS (51).

Osteoporosis is another concern for patients with MS and another source of pain. Cosman et al. (52) reported a history of fractures in the absence of major trauma in 22% of MS patients compared with only 2% of controls (P < 0.002). Determining bone mass by dual X-ray absortiometry, the authors observed that over two years of prospective follow-up both women and men with MS lost substantially more bones than controls. There was a trend, which did not reach statistical significance, for diminished ambulatory status and long duration of steroid therapy to predict higher bone loss. In another study, however, this group noted that "after controlling for age, cumulative steroid use was not a determinant of bone mineral density,''(53) a finding of Schwid et al. (54). However, low vitamin D intake and diminished exposure to sunlight appear to be major contributors to the problem.

Although headache has not been particularly associated with MS, one report cited a patient with severe acute headache, associated with a solitary new lesion in the periaqueductal gray region (55). This unusual case supports observations in patients with implanted electrodes, in which perturbation in this area can produce headache.

In another unusual case, headache, mimicking subarachnoid hemorrhage occurred. A patient with a history of facial myokymia developed apoplectic headache and a third nerve palsy. Investigations revealed no evidence of subarachnoid hemorrhage or aneurysm, but MRI showed more than 30 white matter lesions, and CSF examination revealed oligoclonal bands (56).

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